I hereby authorize Rabbi Michael Stanger of Old Westbury Hebrew Congregation of Old Westbury, NY to sell transfer, and assign all Chametz of whatever kind and nature which I possess, or in which I may have an interest, wheresoever situated, in my residence or in my place of business, or in any other place, without reservation and limitation.
 

Please provide complete address including apartment # if appropriate.

Please acknowledge the following:
THE EFFECTIVENESS OF THE SALE DEPENDS ON THE CHAMETZ BEING ACCESSIBLE TO THE NON-JEWISH PARTY TO WHOM IT IS SOLD.PLEASE CLEARLY INDICATE HOW THE CHAMETZ CAN BE ACCESSED FOR ALL OF PESACH. ACCESS TO CHAMETZ (INCLUDING TIMES WHEN I AM NOT AT HOME) CAN BE ARRANGED BY CONTACTING.
(if you are home for all of Pesach, put your contact information here, otherwise put a contact who can access your home):

Optional Donation:
It is customary to make a donation. There is no charge for the service of acting as your agent for the Sale of Chametz. Suggested donation of $18 or more.